(From Pediatric Directions, Issue 38)
Rumination syndrome is an increasingly recognized chronic, functional gastrointestinal disorder in the pediatric population. It is sometimes confused with other gastrointestinal problems, such as gastroparesis, gastroesophageal reflux disease or eating disorders. Gastroenterologists and psychologists at Nationwide Children’s have led an interdisciplinary team to develop the first inpatient pediatric rumination syndrome program to diagnose and successfully treat patients with this condition. Once patients successfully complete the program, they have the skills needed to self-manage their disorder and ingest food without vomiting. As a result, these patients maintain the calories and fluid their bodies require for proper growth and development.
Since rumination syndrome is often confused with other gastrointestinal problems, such as gastroparesis or gastroesophageal reflux disease or eating disorders, Nationwide Children’s gastroenterologists and psychologists often use the Rome III Criteria (See Table below), combined with antroduodenal manometry to accurately diagnose the patient. Once diagnosis is confirmed to be rumination syndrome, the patient is evaluated to determine readiness and appropriateness for the inpatient treatment program. Patients typically are involved with the program for approximately two weeks. Once patients successfully complete the program they have the skills to self-manage their rumination.
While these symptoms are common to patients with rumination syndrome, each patient with rumination syndrome typically has a different presentation. For instance, some patients vomit immediately after eating even one bite of food, while others are able to eat a large portion of food before the rumination starts. Some patients experience pain or nausea with eating, and some patients do not have any sensations before the rumination begins.
Although we do not know exactly how rumination syndrome starts, medical histories of patients with the syndrome suggest that the symptoms often begin with some “triggering” event. This can be a viral infection, a gastrointestinal disease, or even stress happening in the patient’s life. After this infection, event or stressor has gone away, the vomiting behavior remains in place, almost similar to a “tic” or a “habit.” As a consequence, when food or liquid enters the stomach, the body has learned a new behavior – contraction of the abdominal muscles – that results in the food or fluid coming back up.
In addition to pediatric psychology and gastroenterology involvement, specialty services, such as massage therapy, therapeutic recreation, child life and clinical nutrition, play an integral role in treating severe rumination cases.
Another strategy is the use of progressive increases in the size of meals for rumination syndrome patients. The feeding process for many patients begins with a tiny amount of food and then slowly increasing intake as the patient demonstrates success with keeping food and fluid down. Implementing the entire inpatient management program in an outpatient setting would be quite difficult. However, children who have milder forms of rumination syndrome may be successfully managed on an outpatient basis.
Diagnosis / Referral: Patient was referred to the Motility Center for diagnostic testing at Nationwide Children’s to better understand her recurrent vomiting. The vomiting began two and a half years prior to the referral, around the time she had focused on losing weight. She began to experience challenges with her eating and an over-focus on losing weight. She was hospitalized with an eating disorder. As her vomiting after meals continued, she required placement of a J-tube to support her nutrition and hydration needs. Even during treatment for her eating disorder, those working with her noted that her vomiting pattern appeared to be different than might be anticipated, as vomiting typically occurred immediately after eating and could occur mid-sentence. To better understand the nature of her vomiting, the patient was evaluated in our center for antroduodenal manometry. Results of testing clearly identified post-prandial rumination waves that were associated with the effortless emesis of ingested foods. She was then re-admitted to our inpatient program for treatment of her rumination. Close observation of her at mealtime suggested that she tended to eat somewhat quickly. Within five to ten minutes of starting her meal, she described feeling pressure and that the food was “coming up” in her chest.
Treatment: Her treatment included education about rumination and awareness training, so that she better recognized both the signals of impending rumination and the abdominal contractions that accompanied the actual vomiting. She participated in biofeedback training. The skills developed included slower, more diaphragmatic breathing that allowed for a reduction in sympathetic nervous system activity. She was trained to utilize this skill during and after mealtime. Meals were structured with an emphasis on slower intake of gradually larger amounts of food, with the goal at each meal not to vomit and re-swallow any food that may come up her esophagus. This training was conducted so that she could tolerate gradually greater amounts of food and fluid in her stomach and be able to manage the associated discomfort. In addition to psychology and gastroenterology, her day was structured with therapies including massage, therapeutic recreation and child life. All clinicians worked together toward common goals of managing the patient’s symptoms.
Outcome: Over the course of eight days, the patient developed the skills needed to keep down enough calories and fluid to maintain her weight and hydration without the need for J-tube supplementation. Although some occasional rumination was present, it did not result in any expulsion of food or fluid.
Post discharge, the patient has renewed energy and is enjoying her regular activities again, such as softball and swimming. She is now able to eat lunch with her peers at school. She has begun trying new foods and is tolerating them well. Her most recent checkup with her primary care physician showed that all her vital signs were normal, she grew ½ inch taller and she has maintained her weight. Due to her progress, she is gradually being taken off all medications and no longer needs nutritional supplements via J-tube.
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